不同手術方式乳癌病患認知、滿意度、健康相關生活品質之縱貫性研究

研究背景與目的: 女性乳癌為全世界最常見女性癌症之一，女性乳癌發生率在世界各地皆有逐漸成長趨勢。台灣乳癌近十年來之發生率一直蟬聯十大女性癌症之冠，而發生率也是逐年上升。現今常見治療乳癌的手術方式有乳房保留手術(Breast Conservation Surgery, BCS)與改良型乳房切除手術(Modified Radical Mastectomy, MRM)以及改良型乳房切除術合併自體組織重建手術(Breast Reconstruction, TRAM)。乳癌病患術後之健康相關生活品質(HRQoL)的研究逐年上升，但在台灣類似乳癌病患縱貫性之生活品質研究並不常見。故本研究針對台灣兩家醫學中心等級醫院之乳癌病患進行縱貫性健康相關生活品質追蹤，以探討台灣女性施行三種乳癌術式病患健康相關生活品質、認知與滿意度之整體性研究。研究方法: 本研究以前瞻性研究設計(Prospective Study Design)蒐集兩家醫學中心層級醫院接受MRM、BCS、TRAM分別為147位、86位、37位，共270位病患。針對病患、醫療機構、照護品質相關特性等進行追蹤研究，以問卷評估病患之術後一個月認知、滿意度以及術後一年HRQoL之改善趨勢，最後再探討影響乳癌病患HRQoL之因素。研究結果: 本研究發現三種乳癌術式病患的病患、醫療機構、照護品質相關特性多數達顯著差異；但三種乳癌術式病患的病患術前多數HRQoL構面皆未達顯著差異。在三種乳癌術式病患之術後一年HRQoL改變趨勢上，可發現三種乳癌術式病患因手術後輔助性治療的介入，使其在術前至術後三個月的功能性與症狀性構面分數改變趨勢最為顯著，術後三個月至術後六個月的功能性與症狀性構面分數改變趨勢幅度並不大；另三種乳癌術式病患中以MRM病患大部分的功能與症狀性構面最差。在三種乳癌手術方式的各個時間點療效改善差異上，可發現三種乳癌術式手術後初期以BCS與TRAM病患功能恢復較佳，而MRM病患這段期間症狀較差；手術後三個月到六個月，可以發現BCS病患這段期間功能較差以及症狀較多；到了療程後半期約一年的時候，可以發現BCS病患功能恢復較佳而MRM病患這段期間症狀較差，另發現TRAM病患在這段期間其部分功能與症狀構面有變差的傾向。在三種乳癌術式病患認知與滿意度上，病患術後滿意度總分上有達顯著性統計水準差異。認知與健康相關生活品質改變幅度相關中，可發現病患之術後認知與大部分功能性構面皆呈現顯著性負相關，症狀性構面可發現大多呈現顯著性正相關；另發現病患之術後滿意度與大部分功能性構面皆呈現顯著性正相關；與症狀性構面可發現大多呈現顯著性負相關。分析乳癌病患之影響術後認知、滿意度迴歸模式中，可以發現年齡、教育年數、與家人同住在一起、術前狀況對乳癌病患術後認知與滿意度具有顯著預測力。在分析不同或不分乳癌術式病患之影響術後HRQoL迴歸模式中，可以發現時間、年齡、教育狀況、手術方式、ASA麻醉等級、輔助性治療、術前狀況為影響乳癌病患術後HRQoL的影響因子。結論與建議: 三種乳癌術式病患之病患、醫療機構、照護品質相關特性之間有顯著性差異，但手術前HRQoL無顯著性差異。在一年改變趨勢上，可發現三種乳癌術式病患在術前至術後三個月的功能性與症狀性等構面分數改變趨勢最為顯著，而其它時間上功能性與症狀性等構面分數改變趨勢幅度並不大；術後一年發現病患大部分功能皆有改善而症狀皆比術前還來的高，三種乳癌術式病患中以MRM病患大部分的功能與症狀性等構面最差。在三種乳癌術式病患認知與滿意度上，可發現三種乳癌術式病患滿意度總分上有達顯著差異。影響術後HRQoL迴歸模式中，可以發現時間、年齡、教育狀況、手術方式、輔助性治療、術前狀況為影響乳癌病患的術後HRQoL的影響因子。故未來醫療機構人員應重視不同乳癌術式病患術後認知與滿意度以及HRQoL，以提升乳癌病患HRQoL與滿意度，去改善台灣乳癌病患之治療環境。

關鍵字

乳癌；乳房保留手術；改良型乳房切除術；重建乳房手術；認知；滿意度；健康相關生活品質

並列摘要

Background & Purpose: Breast cancer is the most common female cancer in the world, and its incidence tend is gradually increasing. In recent decade, the incidence of breast cancer remains the top of the ten most occurrence of female cancers in Taiwan. Most popular breast cancer treatment method is the Breast Conservation Surgery (BCS), Modified Radical Mastectomy (MRM) and Breast Reconstruction Surgery (TRAM). The importance of health-related quality of life (HRQoL) for the breast cancer patient is increasing, but few studies are available in Taiwan. The purpose of this study was to explore the impact factors of perceptions, satisfactions and HRQoL of patients under three types breast cancer surgery in two major medical centers of Taiwan. Method: This prospective study covered 270 breast cancer patients (147 MRM, 86 BCS and 37 TRAM treated patients) from two medical centers. The studies focus on patient demography, medical condition and care quality relevant factors of breast operation. It uses structural formula questionnaire to analyze patient’s perceptions, satisfactions and one year HRQoL. We also predict the influencing factors on breast cancer patient’s HRQoL by using the GEE method. Result: There was significant difference of age, educational years, menopausal status, child numbers, family heritage history, tumor stage, operation time, anesthesia time, radiotherapy, hormone therapy, admission days, complication, Body Image, Sexual Enjoyment, Future Perspective, Sleep Disturbance, Diarrhea, Financial Difficulty, Role Limitation due to Emotional problem on three types of breast cancer patients. Due to adjuvant therapy after operation, three surgical types of breast cancer patients had high significant functional and symptoms scores at the 3rd month follow-up but reached a plateau at the 3rd to 6th month follow–up. MRM patients showed the poorest HRQoL through the study period. Curative effects in all surgical types at each time point are different. BCS patients and TRAM patients had better HRQoL at early follow up stage, but MRM patients had poor ones. Moreover, BCS patients had poor function and better symptoms in this period. BCS patients had better HRQoL, MRM patients had poor ones, but TRAM patients’ HRQoL were found to deteriorate. There was significant difference on patients’ satisfactions in three surgical types. There was negative correlation between perceptions and most functional dimensions, and positive correlation between perceptions and most symptom dimensions. On the other hand, there was positive correlation between satisfactions and most functional dimensions and negative correlation between satisfactions and most symptom dimensions. Age, education, living with family, tumor grade, hair loss and upset, Physical Function can predict patient’s perceptions in BCS patients; menopausal status, Body Image, Physical Function, Bodily Pain can predict patient’s perceptions in MRM patients. Global health status, Role Function, Financial difficulty, Role Limitation due to Emotional problem can predict patient’s perceptions in TRAM patients; educational year, living with family, tumor grade, operation type, admission days after operation, Body Image, Physical Function, Bodily Pain can predict patients’ perceptions. Menopausal status, tumor grade, hair loss and upset, Physical Function, Bodily Pain can significantly predict satisfactions in BCS patients; living with family, BMI, tumor grade, breast symptoms, Physical Function, Cognitive Function, Role Limitation due to Emotional problem work on satisfactions in MRM patients; Body Image, Physical Function on satisfactions in TRAM patients. Generally, age, living with family, Body Image, Breast Symptoms, Physical Function, Cognitive Function and Role Limitation due to Emotional problem can predict patients’ satisfactions. In researching a HRQoL influence model against three surgical types, time, age, tumor grade, ASA score, chemotherapy, complication, pre- operation score are the major factors. Additionally, time, age, educational year, BMI, Menopausal status, CCI, tumor grade, tumor stage, operation type, ASA score, chemotherapy, radiotherapy, hormone therapy, pre- operation score can significantly predict HRQoL after breast cancer surgery. Conclusion: It has been found the patients’ characteristics, medical condition, and quality of care differed significantly in three surgical types. Functional and symptom dimensions changed significantly on the first stage of three months, but, better functional dimensions and worsen symptom dimensions were shown in one year after the operation. MRM had poorest functional and symptom dimensions. There was significant difference on satisfactions among different surgical types. Time, age, tumor grade, tumor stage, operation type, ASA score, chemotherapy, and Pre-operation score can predict HRQoL. Medical provider should recognize and stress the importance of HRQoL for breast cancer patients so to promote satisfactions and improve quality of care environment in Taiwan. Key word: Breast cancer, Breast Conservation Surgery, Modified Radical Mastectomy, Breast Reconstruction surgery, Perception, Satisfaction, Health-related quality of life

並列關鍵字

Breast cancer ； Breast Conservation Surgery ； Modified Radical Mastectomy ； Breast Reconstruction surgery ； Perception ； Satisfaction ； Health-related quality of life